Is it standard to combine Plavix (clopidogrel) and Eliquis (apixaban) in a patient with persistent atrial fibrillation (AFib) and Barrett's esophagus, who is already taking pantoprazole, 4 weeks after coronary bypass surgery?

Combining Eliquis (Apixaban) and Plavix (Clopidogrel) After Coronary Bypass in a Patient with Persistent AFib and Barrett's Esophagus

For a patient with persistent atrial fibrillation who is 4 weeks post-coronary bypass surgery, dual therapy with Eliquis (apixaban) and Plavix (clopidogrel) without aspirin is the recommended antithrombotic strategy, even with Barrett's esophagus and pantoprazole use. 1

Antithrombotic Strategy After Coronary Bypass with AFib

Recommended Approach

• For patients with AFib at increased risk of stroke (CHA2DS2-VASc score ≥2) who have undergone coronary revascularization, double therapy with a P2Y12 inhibitor (clopidogrel) and an oral anticoagulant is recommended over triple therapy to reduce bleeding risk 1
• At 4 weeks post-CABG, the patient is in the period where anticoagulation for AFib should be prioritized while maintaining protection against graft thrombosis 2
• The 2019 AHA/ACC/HRS guidelines specifically recommend double therapy with a P2Y12 inhibitor and an oral anticoagulant for patients with AFib who have undergone PCI or ACS, which can be extrapolated to post-CABG patients 1

Choice of Anticoagulant

• Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists (warfarin) for stroke prevention in non-valvular AFib 1
• Among DOACs, apixaban (Eliquis) has demonstrated:
  • Lower rates of stroke or systemic embolism compared to warfarin 1, 3
  • Lower bleeding risk compared to other anticoagulants including rivaroxaban 4, 5
  • Higher treatment persistence (82%) compared to dabigatran and warfarin (64%) 4

Choice of Antiplatelet Agent

• Clopidogrel is the preferred P2Y12 inhibitor when combined with oral anticoagulation due to lower bleeding risk compared to more potent agents like prasugrel or ticagrelor 1
• The standard dose of clopidogrel in this setting is 75 mg daily 1

Special Considerations for Barrett's Esophagus

Bleeding Risk Management

• Barrett's esophagus increases the risk of upper GI bleeding, which is further elevated by antithrombotic therapy 1
• Proton pump inhibitor therapy (pantoprazole) is appropriate and recommended for this patient to reduce GI bleeding risk 1
• The use of pantoprazole is compatible with both apixaban and clopidogrel, though there may be some theoretical concerns about reduced clopidogrel efficacy 1

Duration of Therapy

• For patients requiring indefinite anticoagulation for AFib, antiplatelet therapy (clopidogrel) is typically continued for up to 12 months post-revascularization 1
• After this period, discontinuation of antiplatelet therapy and continuation of anticoagulation alone may be considered based on individual bleeding and thrombotic risks 1

Monitoring and Follow-up

• Regular monitoring of renal function is recommended when using apixaban 1
• Vigilance for signs of GI bleeding is particularly important given the patient's Barrett's esophagus 1
• Endoscopic surveillance for Barrett's esophagus should continue as normally scheduled 1

Potential Pitfalls and Caveats

• Avoid triple therapy (adding aspirin) as it significantly increases bleeding risk without substantial reduction in thrombotic events, especially concerning with Barrett's esophagus 1
• If the patient develops acute GI bleeding, temporary interruption of antithrombotic therapy may be necessary, with apixaban being easier to manage due to its shorter half-life compared to warfarin 1
• The AUGUSTUS trial showed that apixaban plus a P2Y12 inhibitor without aspirin provided the best balance of efficacy and safety, including in patients with prior stroke 6